DATE FILEDFORCOURT USE ONLY Petitioner:NameStreet AddressCity/TownStateZipCodePhoneNumberEmailPersonal estate estimated at: $ Assets unknownName of RespondentRelationship to RespondentStreet AddressCity/TownStateZipCodeEmailPhoneNumberRespectfully requests that:Name of NomineeRelationship toRespondentStreet AddressCity/TownStateZip CodeEmailName of Co-Nominee (if any)Relationship toRespondentStreet AddressCity/TownStateZip CodeEmailor any suitable person may be appointed CONSERVATOR of the above respondent who believes that the respondent has become incapacitated by reason of:advanced agemental weaknessother:and can no longer properly care for his/her property.Attach Form PC-9.1, Waiver, if applicable.Petitioner: To the best of my knowledge or belief, the statement(s) contained within this document are truthful and accurate.Signature of PetitionerDateNotary:Name of NotaryStateCountyOnday of, 20the petitioner, known to me or proved through satisfactory evidence, signed the document in Signature of Notary PublicDateCommission ID#Commission Expiration DateNotary Seal CONSERVATORSHIPRIGL 33-15-44PC-2.10 (Rev. 07/17) State of Rhode Island and Providence PlantationsProbate CourtPage 1 of 2 STATE OF RHODE ISLANDCounty ofEstate ofAlias PROBATE COURT OF THECity or Town ofNo. SIGN HERE American LegalNet, Inc. www.FormsWorkFlow.com DECREEUpon hearing, it is hereby ordered and decreed that said complaints are found true and accurate. Wherefore, the following is/are appointed CONSERVATOR(S):AppointedConservatorRelationship toRespondentStreet AddressCity/TownStateZip CodeEmailPhone NumberAppointed Co/ConservatorRelationship toRespondentStreet AddressCity/TownStateZip CodeEmailPhone NumberWith the following limitations on his/her/their authority:Bond Fixed at: $ With Surety Without Surety By Decree herein, the following is/are appointed APPRAISER(S): Check box if Appraiser(s) is/are the same as above OR Complete Appraiser(s) information below. Appraiser NameStreet AddressCity/TownStateZip CodeEmailPhone NumberCo-Appraiser NameStreet AddressCity/TownStateZip CodeEmailPhone NumberAppointed RESIDENT AGENTResident Agent NameStreet AddressCity/TownStateZip CodeEmailPhone NumberEntered as an order and decree of the court on:Probate JudgeDateSignature of Probate JudgePC-2.10 (Rev. 07/17) Page 2 of 2 SIGN HERE American LegalNet, Inc. www.FormsWorkFlow.com